Management of Intraoperative Endo-Sinus Communications in Maxillary Posterior Teeth: A 15-Case Series

Background
The anatomical relationship between posterior maxillary teeth and the maxillary sinus may predispose to intraoperative complications during endodontic treatment. While sodium hypochlorite extrusion into the sinus has been sporadically reported, no case series has described direct intraoperative endo-sinus communications.

Methods
Fifteen cases of intraoperative endo-sinus communication were documented during root canal treatment or retreatment of maxillary premolars and molars. Clinical signs included profuse bleeding synchronous with respiration, the presence of nasal mucus in the pulp chamber, disappearance of sodium hypochlorite solution, and contamination of paper points. In all cases, a Valsalva maneuver was performed and confirmed the presence of communication. Management strategies included immediate obturation when the canal could be dried or hemostasis achieved, or provisional sealing with Teflon and IRM with or without calcium hydroxide dressing when immediate obturation was not possible. Patients were followed clinically and radiographically.

Results
In 4 cases (26.7%), endodontic obturation was completed in a single visit, while in 11 cases (73.3%) obturation was postponed. Among the latter, 4 cases received calcium hydroxide dressing and 7 had no intracanal medicament. In all cases, the communication resolved spontaneously within one week. At a mean follow-up of 3.9 years (range: 1–10 years), no patient developed persistent sinonasal symptoms or radiographic evidence of sinus pathology.

Conclusions
This case series provides the first clinical description of intraoperative endo-sinus communications. When promptly recognized and appropriately managed, these events do not appear to compromise the long-term prognosis of endodontic treatment. Careful preoperative radiographic assessment, accurate working length determination at the first appointment, and controlled instrumentation are essential to prevent recurrence. Different obturation techniques may be successfully applied, with bioceramic sealers offering potential advantages in postoperative comfort.